Page 86 - Cover Letter & Evaluation for Michael Novotny
P. 86
6/9/2018 Your Medicare Health Plan Details
Preventive care $0 copay
Emergency care/Urgent care Emergency: $80 per visit (always covered)
Urgent care: $30-50 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $0 copay
services/imaging
Lab services: $0 copay
Diagnostic radiology services (e.g., MRI): 20%
Outpatient x-rays: $0
Mental health services $150 for days 1 through 5
$0 for days 6 through 90
Outpatient group therapy visit with a psychiatrist: $30
Outpatient individual therapy visit with a psychiatrist: $30
Outpatient group therapy visit: $30
Outpatient individual therapy visit: $30
Skilled Nursing Facility $0 for days 1 through 20
$160 for days 21 through 51
$0 for days 52 through 100
Rehabilitation services Occupational therapy visit: $10
Physical therapy and speech and language therapy visit: $10
Ambulance $250
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment: $10
Routine foot care: Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item
Prosthetics (e.g., braces, artificial limbs): 20% per item
Diabetes supplies: $0 per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy: 20%
Other Part B drugs: 20%
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Benefits Services
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